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The Three C Approach to Personal Safety During the Covid-19 Pandemic

The UK is facing a surge in Covid-19 infections from the Omicron variant of SARS-CoV-2 coronavirus with a record number of Covid-19 cases (78,610) reported in the UK today. Cases of Covid-19 due to Omicron will soon account for most infections in the UK. Omicron has proved to be highly infectious – more so than other variants of SARS-CoV-2 – and is also able to evade vaccines better than other variants. To protect yourself, and reduce the risk of infection to you and others remember the three C approach to personal safety:

– Avoid closed spaces

– Avoid crowded spaces

– Avoid getting too close to other people when outside your household

These are simple and effective messages that need to be disseminated and adopted widely.

Remember also to get vaccinated – including with a booster as well as your first two doses – and to wear a good quality FFP2 mask when in indoor spaces outside your home. Three doses of vaccines provide much better protection against symptomatic Covid-19 infection than one or two doses. Test regularly with lateral flow devices. These don’t pick up all infections but can help identify the people who may be most infectious.

Finally, remember to improve ventilation whenever you are indoors, particularly with people from outside your household. The virus that causes Covid-19 (SARS-CoV-2) is airborne. Good ventilation can help  disperse the virus and reduce the concentration in the air, thereby lowering the risk of infection.

When vaccination, testing and ventilation are combined with wearing a higher quality face mask and adopting the 3C approach, you are reducing the risks of infection for you and the people close to you when you follow this guidance.

Covid-19 booster vaccination questions answered

When am I allowed to have my booster?

You can have your booster Covid-19 vaccine once you are three months past your second vaccine dose. The gap was previously six months but has now been reduced.

Who is eligible for a booster?

Anyone aged 18 and over is now eligible for a booster. People aged 16-17 with underlying health conditions that put them at higher risk of severe Covid-19 are also eligible for a booster. The NHS will aim to vaccinate people in order of clinical priority.

Can I have a booster if I’ve never been vaccinated?

You can’t have a booster until you are three months past your second Covid-19 vaccination. If you have not been vaccinated, you will need to have your first two vaccine doses eight week apart and then get your booster three months after your second dose People who are not vaccinated are at much greater risk of a serious Covid-19 illness, hospitalisation and death. So please do come forwards for vaccination if you are currently unvaccinated.

Does anything stop me from receiving a booster? (e.g., you need to wait if you’ve have Covid recently or received a flu jab)

If you have recently had another vaccine (e.g., flu) and your Covid-19 vaccine booster is due, you should still go ahead with this rather than delay your booster. Getting your booster promptly means that there is then not a delay in getting further protection from the booster. The only exception to this is the shingles vaccine, where a seven day interval should be observed between the vaccines.

Are booster jabs safe for everyone?

Research has shown that Covid-19 vaccines, including boosters, are very safe with only a very small risk of serious side-effects. The risks from a Covid-19 infection are far higher than from vaccination.

Why are boosters all of a sudden more urgent?

The immunity provided by Covid-19 vaccines begins to weaken after a few months. A booster vaccine substantially increase people’s protection from serious illness. Another reason why boosters have become more important is that the UK is now facing a wave of infection from a new Coronavirus variant, Omicron, which is more infectious than the previous Delta variant. Two doses of vaccines work less well against Omicron than Delta. A booster dose will provide a lot more protection against Omicron than provided by two doses. Ensuring that people receive a booster dose will reduce the number of people who are seriously from Covid-19, and keep down deaths and pressures on the NHS.

Can pregnant women have boosters?

Pregnant women are eligible for boosters and should get one when this is due. The vaccines being used for boosters have been shown to be safe during pregnancy for both the mother and baby.

Where can I get my Covid booster?

Boosters are available from a range of sites. This includes NHS vaccine centres, GP surgeries and pharmacies. You will need to check where the sites are in your local area as not all hospitals, pharmacies and GP surgeries are offering boosters.

Do I need to book or can I go to walk-in centre?

In the past, it was possible to go to a walk-in centre for a Covid-19 vaccination. However, because of the very high demand that there will now be for boosters, you may find that there is a very long queue or that you are turned away if you attend without an appointment.

What advice would you give to someone who is hesitant about the booster?

Covid-19 is a very serious illness. Vaccines are a safe way to protect yourself from these risks. By getting vaccinated, you are also helping to protect others – such as older family members or family members who are clinically vulnerable because of their medical problems. Vaccines have been fully tested and were shown to be safe and effective in clinical trials before they went into general use. We have now given many billions of vaccine doses globally, so we have excellent data in their safety and effectiveness from countries across the world.

A version of this article was first published in the Daily Mirror.

Staying safe this Christmas in the midst of an Omicron Covid-19 wave

The number of Covid-19 cases in the UK has increased in recent weeks to an average of around 50,000 per day. The number of cases caused by the Omicron variant, although currently small, is doubling about every three days. If this increase continues, Omicron will replace Delta as the most common variant of the Coronavirus in the UK within a few weeks. This is concerning because it looks like our current vaccines may be less effective against the Omicron variant than against the Delta variant. The good news though is that three doses of a vaccine (the first two doses followed by a booster dose) should continue to provide good protection from serious illness, even if current Covid-19 vaccines are a little less effective against Omicron. To help counter the threat from Omicron and limit the pressures on the NHS, the government is introducing new measures in England to reduce the risk of infection. As well as following the new rules, you should also ensure you are fully vaccinated – including receiving a booster vaccine – and use lateral flow test before attending events or meeting others from outside your household. Some people with weak immune systems will need four vaccinations before they are fully vaccinated. And remember that if at any point you develop symptoms of a possible Covid-19 infection, get a PCR test and isolate until you get the result of the test.

I’m having my family over for Christmas dinner, but some of them are unvaccinated. What should I do?

People who are unvaccinated are more likely to become infected with Covid-19 and transmit infection to others. If you have vulnerable family members – such as elderly relatives – joining you for your Christmas dinner, my advice would be for your unvaccinated relatives not to attend. If they do attend, you should aim to reduce the risk of infection by asking them to carry out a lateral flow test before they visit. You should also improve the ventilation in your house as this will also reduce the risk of infection.

My elderly mother missed Christmas last year. Can she come round this year?

People from different households can mix indoors this year, so your mother can come round. Ideally, everyone eligible for a vaccine who is present should be fully vaccinated (including boosters) and take a lateral flow event before your mother arrives. Children under 12 are not currently eligible for a vaccine. They should also take a lateral flow test as there is currently a high Covid-19 infection rate in children.

I’ve booked to go with my family of four to a West End musical over Christmas. Can we still go?

Theatres remain open. You will be required to wear a mask whilst in the theatre. Currently, a COVID pass is not needed for entry to a theatre but it is a good idea for everyone to carry out a lateral flow test before leaving home for the theatre.

My work is throwing a big Christmas party for all 50 employees. Will it still go ahead, and if so, will it be safe to go?

Christmas parties can still go ahead but many employers are cancelling them because of the risk of infection in crowded, indoor settings; particularly where ventilation is poor. A COVID pass is not required for entry to the party but if the event does go ahead, ideally, everyone attending should ideally be fully vaccinated and take a lateral flow test before the event. If you are clinically vulnerable through age or a medical condition, or live with someone who is clinically vulnerable, my advice would be not to attend the event even if fully vaccinated because of the risks from a breakthrough infection.

My department is planning a Christmas lunch with around 15 people. Is that still allowed? What precautions should we take?

Christmas lunches organised by employers can go ahead. Everyone attending should aim to be fully vaccinated and take a lateral flow test before the event. People who are clinically vulnerable – or live with someone who is clinically vulnerable – should consider missing the event.

Will my kids’ school Christmas play still be allowed to happen, and if so, what extra restrictions might there be?

School Christmas plays can go ahead. However, many schools are limiting the number of people who can join the event, meaning that parents may not be able to attend. If you are allowed to attend, you should wear a face mask and take lateral flow test before attending. Ensure that you are also fully vaccinated.

What precautions should I take when I go Christmas shopping?

Wear a face mask whilst indoors and on public transport. An FFP2 mask provides greater protection and many public health specialists advise the use of these rather than standard surgical masks. Wash your hands or use had sanitiser before and after leaving shops.

Is it safe for my children to have friends around to play over the Christmas holidays?

Children can have their friends round. A lateral flow test for everyone can help in reducing the risk of infection. Ventilation can also help reduce infection risk. Younger children (under 12) are not currently eligible for a Covid-19 vaccination.

What will happen to the Christmas Eve midnight mass we all normally go to?

Religious events can still go ahead and are exempt from the from requirements to use the NHS COVID Pass. A face mask will be required whilst indoors in the church. To reduce the risk of infection further, everyone attending should be fully vaccinated and take a lateral flow test before attending.

Will me and my mates still be able to have our traditional festive drinks evening at the pub?

You can still have your festive drinks with your friends. As the venue is likely to have less than 500 people, the NHS Covid Pass in not needed to enter. A face mask is not required either. You should remember however that indoor events like this carry a risk of infection because the venue may be crowded and social distancing will not be possible. Ensure you are fully vaccinated and use a lateral flow test before the drinks event.

A version of this article was first published in the Daily Mirror.

Why face masks are important in controlling the spread of Covid-19

The government announced today that face masks will be mandatory in England from Friday 10 December in a wider range of settings. Why is this an important step in controlling the spread of Covid-19?

Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but only if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification FFP2 mask is worn that filters out more particles and droplets when the wearer breathes in air.

Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19. Vaccines are essential and can protect us from developing a more serious illness, as well as reducing the risk of death. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic.

How worried should we be about the omicron variant?

How worried should we be about the omicron variant?

When any new variant of the virus that causes Covid-19 is identified, we don’t at first know how infectious it will be; whether it will cause a more serious illness than other variants; and how well vaccines will work against it. We therefore need to be cautious and take measures to control the spread of Omicron until this information becomes available. We shouldn’t however become unduly anxious.

I’ve heard that the variant causes more mild symptoms. Is that true and if so why are we worried?

Some early reports from South Africa suggest that Omicron may cause a milder illness than other variants. However, we will need data from many more people infected with the Omicron variant – particularly, older and clinically vulnerable people – before we can reach reliable conclusions about the severity of the illness it causes.

Why are they giving more booster jabs if the new variant can evade existing vaccines?

Two doses of current vaccines provide good protection – and three doses provides event better protection – against the other strains of coronavirus. At present, we have no evidence that the Omicron variant can evade existing vaccines. We need to continue with the booster programme as this has been very effective in keeping down the number of serious infections that can result in hospital admission or death.

Does the new variant transmit any differently?

We don’t yet have good data on whether Omicron can infect people more easily than other variants. This data will gradually emerge in the coming weeks.

Does it mean existing Covid treatments like the new antiviral treatments won’t work either?

It is possible that some of the newer antiviral treatments won’t work as well against Omicron as against other variants. However, this will need to be confirmed in research studies. It’s very likely however that antiviral treatments will still reduce the severity of illness caused by Omicron.

What don’t we know about omicron and when will we know?

We currently lack important information about Omicron – such as how infectious it is; whether it causes a more severe illness than other variants; how well vaccines protect against it; and whether antiviral drugs will be helpful in reducing the severity of illness it causes. Research is already underway to answer these questions.

How likely is it to affect Christmas and how?

We currently have a high Covid-19 infection rate in the UK. Fortunately, vaccines are keeping down the number of people with a more severe illness, which in turn is keeping the number of hospital admissions and deaths low. If we can get a high uptake of boosters in adults, we should be able to have a more normal Christmas this year. But everyone should continue with good infection control measures and not rely just on vaccination. People who are not vaccinated at all (around 11% of people aged 12 and over in the UK) should also come forwards for vaccination.

Will wearing masks really stop it?

Masks can reduce the spread of infection – particularly if a higher specification FFP2 mask is worn. When combined with other infection control measures such as vaccination and home working, masks can help reduce the spread of infection.

Will bringing forward boosters mean they’re not as efficient?

Brining forward the booster to three months instead of six months after people’s second vaccination won’t reduce its effectiveness in preventing serious illness. The booster dose substantially increases people’s immunity and this can help stop the Omicron variant evading our current vaccines.

What will happen in schools?

Many schools in England have had large Covid-19 outbreaks since September when the new school year started. It’s important that 12-15 year old children are vaccinated and also get a second vaccination once the government has approved this. People working in schools also need to be fully vaccinated with three doses (four doses for people with weak immune systems). Any child who is unwell with symptoms of a possible Covid-19 infection should get a PCR test and isolate until the result is back. Improving ventilation and air quality in schools is also essential to reduce the risk of infection.

Could there be more travel bans?

If the Omicron variant spreads further, then more countries may be placed on the government’s Red List. This can happen with very little notice, leaving travellers with the option of either cutting short their trip and returning quickly to the UK; or facing an expensive stay in a quarantine hotel. Everyone should consider this if they are planning an overseas trip in the next few weeks.

A version of this article was first published in the Daily Mirror.

 

The JCVI is recommending booster Covid-19 vaccines for all adults – why is this essential for the UK’s pandemic response?

The NHS is now rolling out booster doses of Covid-19 vaccines. Today, the JCVI recommended that all adults in the UK should receive a booster. Why do we need these boosters?

The number of Covid-19 cases in the UK is currently around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than many of our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from the UK and elsewhere shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily. There also needs to be sufficient capacity in the vaccination programme to allow as many people as possible to be vaccinated before Christmas.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 40 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. The NHS will now be extending the booster programme to all adults based on the advice issued today by the JCVI.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further infection control measures. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like Omicron may spread further and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

Covid-19 vaccine boosters: Why they are important

The NHS is now rolling out booster doses of Covid-19 vaccines. Why do we need these boosters and who can receive them?

The number of Covid-19 cases in the UK is around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than all our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from other countries shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further lockdown. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

A high take-up of boosters will also reduce the chances of new virus mutations from developing. This year, we have seen the rapid spread of the delta variant of the SARS-CoV-2 virus across the world, including in the UK. Recently, a new version of the delta variant, the AY.4.2 subvariant, has been detected in the UK. This variant is causing concern because it may be more infectious than the original delta variant.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like AY.4.2 may spread and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

On 15 November 2021, the JCVI announced that people aged 40-49 would also be eligible for booster doses of a Covid-19 vaccine.

Why you should get your Covid-19 booster and flu vaccine

The NHS is now rolling out booster doses of Covid-19 vaccines and flu jabs.

The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill.

However, no vaccine is 100% effective. Some Covid-19 infections will still lead to a serious illness, even in people who have received two doses of vaccine. Flu will also be a threat this winter.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in people with medical problems. A booster (third) dose of a vaccine improves your immunity and reduces your risk of a serious illness.

We want as many people as possible to receive Covid-19 boosters and flu jabs before the onset of winter when pressures on the NHS increase.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with certain medical conditions. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. These groups are also eligible for a flu jab.

If people don’t attend for their vaccinations this will lead to more cases of Covid-19 and flu, and increased pressures on the NHS during the winter. The number of deaths will also increase. This then may require the government to bring back some Covid-19 restrictions.

By getting a Covid-19 booster and a flu jab, you are protecting yourself and the other people you live and work with. So please go out and get your vaccinations as soon as you can.

A version of this article was first published in the Daily Express.

Why I don’t support GPs taking industrial action

I don’t support the BMA’s view that NHS GPs in England should consider taking industrial action. I think this will alienate the public and lose GPs support at a critical time. NHS England is not going to invest adequately in the current independent contractor model of general practice. Why does the BMA not ballot GPs about the NHS salaried option instead whereby GPs and their staff would become NHS employees?

The BMA’s GP Committee has always opposed the option of GPs becoming salaried employees of the NHS. For many years, NHS England has been unwilling to fully support the independent contractor model of NHS general practice. Instead, we are going to find the independent model gradually fading and GPs increasingly being employed by commercial companies contracted to deliver NHS services.

This will be a much worse outcome for GPs and patients than other alternatives. And in anticipation of all the responses from GPs about why the current independent model is better than salaried NHS employment, I know these arguments well and list them in a blog I published in 2013. I have been a GP partner for over 20 years and know how this model of NHS primary care works, including its strengths and weaknesses.

I make the counter argument about why we should pursue the option of GPs becoming salaried employees of the NHS (like the > 1m current NHS employees in the UK ) in an article I published in the BMJ in 2016. The BMA needs to consider this employment model seriously if it is to make working as a primary care doctor viable.

All the BMA’s attempts to prop up the independent contractor model of general practice in their negotiations and discussions with NHS England over the last 10 years have failed. Their latest attempt will also fail.

What can we do to reduce the risk of another lockdown this Winter?

We all want to avoid another lockdown. We need sustainable public health interventions that will keep Covid-19 cases, hospitalisations and deaths at an acceptable level, and get us through the winter. What could this mean in practice?

1. The most important public health intervention to control Covid-19 is our vaccination programme. This has slowed down in recent months. Also, in effect, it has split into four distinct programmes:

– a programme aimed at people 16 and over. This has almost stopped, with around 10% of adults in the UK still unvaccinated (higher in London).

– a third primary dose programme aimed at people with weak immune systems. This has been poorly planned and implemented by NHS England and has caused a lot of confusion.

– a booster dose programme. This is going OK but could be speeded up to provide more protection for key groups of people before the full onset of winter.

– a programme for 12-15 year olds. This has got off to a very slow start in England.

Speeding up all these vaccination programmes is essential and is our best defence against Covid-19.

 

2. Try to reduce social contacts; for example, by asking staff to work from home where possible. The government has been encouraging people to “get back into the office” but I think we should be cautious over the winter.

 

3. Face masks. The government needs to reconsider its policy. In my view, face masks should be required in settings such as shops and public transport.

 

4. Vaccine mandates / vaccine passports / negative test results. Many European countries require these for entry to higher risk settings such as nightclubs, bars and indoor events. No vaccine is 100% effective but the fact is that an unvaccinated person is much more likely to become infected and transmit infection to others than a vaccinated person. The government has flipped-flopped on this policy (currently against) but have said they may reconsider.

 

Effective measures now can help bring Covid-19 under control, protect public health, keep pressures on the NHS manageable, and get us through the Winter.